Please tell us about any surgeries you have had in the past. Please include dates with each procedure.

Please list all medications that you are currently taking

Please list any medical allergies you have.

CURRENT STATUS

Check any of the following that pertain to you:

Past

Present

Stress

Panic

Guilt

Recent death

Inferiority Feelings

Shyness

Marriage

Emotional Abuse

Temper

Unwanted Thoughts

Bad Dreams

Impulsive Behavior

Sexual Probloems

Legal Matters

Drug Use

Career Choices

Self-harm

Nervousness

Unhappiness

Apathy

Grief

Fears

Communication

Verbal Abuse

Anger

Concentration

Memory

Self-Control

Pregnancy

Trauma

Alcohol Use

Ambition

Being a Parent

Disaster

High Risk Behavior

Anxiety

Depression

Terminal Illness

Hopelessness

Loneliness

Friends

Physical Abuse

Aggressiveness

Racing Thoughts

Loss of Control

Sexual Abuse

Compulsivity

Abortion

Trouble with Job

Eating Problems

Making Decisions

Finances

Smoking (tobacco)

Zoning out/blanking out

Rate your current level of distress on a scale of 0 - 10.

Are you currently having any suicidal thoughts?

Yes No

Have you had suicidal thoughts in the past?

Yes No

Have you ever attempted suicide?

Yes No

If Yes to above, please indicate when and by what means:

Have any of your friends or family members ever attempted or completed suicide?

Yes No

If Yes to above, please indicate when and what family member or friend:

NOTICE OF PRIVACY PRACTICES

This notice describes how and why your health information may be used and how you can gain access to this information. Please review the information carefully.

(If there are any areas which you might need more clarification on please do not hesitate to ask.)

Why A Privacy Policy Now?

The most significant variable which motivated the Federal government to legally enforce the privacy of health information is the rapid evolution of electronic technology in the health care business. The government has sought to standardize and protect the electronic exchange of your health information. This has challenged us to review how your information is used on our computers, on the Internet, as well as phones, fax machines, and any device used to copy or transfer patient data. We want to advise you that we have developed policies and procedures for our practice to ensure your personal health information will be shared only as required for the purpose of administering your care. Our office is subject to State and Federal laws regarding the confidentiality of your health information. We also want you to understand our procedures and your rights as a valued patient. Your health information will be communicated only for the purpose of conducting health care business. Be assured that without your written permission, your health information will not be used for any other purpose.

Why Your Health Information May Be Used To Provide Treatment:

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information (protected health information) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of I how we are required to maintain the privacy of your health information and how we may use and disclose your health information. Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment, and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include psychotherapy, medication management, etc.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your insurance company for your services.

In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment' options or other health-related services. We will use and disclose your PROTECTED HEALTH INFORMATION when we are required to do so by federal, state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that are authorized by law to collect information; to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding; response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below:

The right to request restrictions on certain uses and disclosures of
PROTECTED HEALTH INFORMATION
, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to request to receive confidential communications of
PROTECTED HEALTH INFORMATION
from us by alternative means or at alternative locations.

The right to request an amendment to your
PROTECTED HEALTH INFORMATION
.

The right to obtain a paper copy of this notice for us upon request. We are required by law to maintain the privacy of your
PROTECTED HEALTH INFORMATION
and to provide you with notice of our legal duties and privacy practices with respect to
PROTECTED HEALTH INFORMATION.

We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

Other than the information stated above, or information that Federal, State, and Local laws require, we will not disclose your health information without your written authorization.

Use your finger (touchscreen) or your mouse to "sign" your full name below:

Client's Signature
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INFORMED CONSENT FOR ONLINE THERAPY

I indicate my understanding of the following and that I have the following rights with respect to online therapy:

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

It is my responsibility to create a confidential environment in which to participate in online therapy. This includes, but is not limited to the following:
a) Using a headset with a microphone to maximize my privacy during sessions.
b) Being in a room with a closed door and closed windows to insure my privacy during sessions.
c) Using private computer equipment for tele-therapy to ensure my privacy during sessions.
d) Taking precautions to protect what I say or what my therapist says from being overheard by another person(s) during sessions.

The therapist is not providing an emergency service, and I have been informed of whom to call in an emergency or during weekend and evening hours.

Conversations with the therapist will be confidential unless prohibited by law, as stated above.

I am financially responsible for this treatment.

I know of no reason(s) that I should not undertake this therapy, and I agree to participate fully and voluntarily.

I have read and received a copy of the HIPAA Notice of Privacy Practices. I have discussed any concerns about the policies with the therapist prior to signing this consent.

I understand that state approved supervisors may review my case with my identity held confidential for the purposes of fulfilling state licensing requirements for my therapist.

I understand that peer-to-peer supervision may be done on a case-by-case basis, and at the discretion of the supervising therapist.

DISCLOSURE STATEMENT

Your decision to enter into therapy was undoubtedly a serious one arrived at after considerable thought. Whether your physician, urged to come by family or friends or have come because of problems and feelings only you know about, referred you the decision to come here was yours.

Therapy is a two-way effort entailing mutual respect, responsibility and consideration between you and your therapist. The policy presented is designed to make your therapy productive and to avoid any misunderstanding regarding the mutuality of the therapeutic process.

As a Marriage and Family Therapist, my area of training is the systemic treatment of individuals, couples, and families. The systemic approach to therapy takes into consideration all immediate family members in family therapy sessions. I, along with you, will decide which family members (if any) need to be included in therapy. Various goals will be established together with you at the outset of therapy.

Therapy naturally involves activities such as identifying emotions and revealing secrets. There may be risks associated with our disclosures to other family members or other family members' disclosures during the course of therapy, as well as exploration of issues. Decisions to disclose will be made by you except where mandated by law. It is expected that some uneasiness or painful emotions may occur, as you are involved in therapy. Discussing painful issues will naturally create discomfort. Your participation in therapy is essential toward helping address your concerns.

The Board of Examiners for the Licensure of Professional Counselors, Marriage and Family Therapists and Psychoeducational Specialists requires that all clients be informed that all forms of dual relationships such as business ventures and sexual intimacy are prohibited.

Please be aware that there is a higher incidence of divorce if only one partner in a relationship is involved in therapy. It is also important that you understand there is no guarantee all of your concerns, issues, or problems will be successfully resolved. I cannot guarantee outcomes. The outcomes may vary from your expectations.

You may discontinue participation in therapy at any time. If you are not satisfied with the course of therapy, please discuss this concern with me.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTOOD THE ABOVE

I have read the above, and I have had my questions answered to my satisfaction. By signing below I state that I have understood what is involved in undergoing treatment and have decided that it is in my best interest to undergo online therapy. Having been informed of the nature and parameters of online therapy, I hereby give my consent to online therapy.

Use your finger (touchscreen) or your mouse to "sign" your full name below:

Client's Signature
*

Clear

Date
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Once you have finished the form, check the 2 boxes above indicating you have read and understood both documents. Then, click "Submit Form" button below and your form will be sent securely to Journey To Truth Counseling, LLC.